Plastic Surgery Research Council
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PSRC 60th Annual Meeting

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Early Surgical Site Infection Following Tissue Expander Breast Reconstruction With And Without Acellular Dermal Matrix: National Benchmarking Using NSQIP
Sebastian Winocour, M.D., M.Sc., Elizabeth B. Habermann, Ph.D., Kristine M. Thomsen, B.A., Valerie Lemaine, M.D., M.P.H..
Mayo Clinic, Rochester, MN, USA.

PURPOSE:
Surgical site infections (SSI) following immediate tissue expander breast reconstruction (ITEBR) with and without acellular dermal matrix (ADM) result in significant patient morbidity and health care costs. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, institutions are now able to query their results and conduct national benchmarking analyses. The purpose of this study is to determine a single institution’s 30-day SSI rate and benchmark it against participating national institutions for quality improvement purposes.
METHODS:
Women who underwent mastectomy followed by ITEBR with and without ADM were identified using the ACS-NSQIP database between 2005-2011. The subset of patients treated at our institution was also identified. Patient demographics, including BMI (<25 vs 25-29.9 vs 30+), smoking status, age 18 and greater, operative time quartiles, preoperative radiation and steroid-use, were evaluated in addition to postoperative SSI rates. Multivariable logistic regression was used to determine patient characteristics predictive of 30-day SSI rate and to identify differences in SSI rates between our institution and the national database.
RESULTS:
Between 2005 and 2011, a total of 12,498 patients underwent ITEBR in the ACS-NSQIP database; of these 264 were at our institution. Of the 12,234 patients outside of our institution, 1894 patients received ADM (15.5%). The percentage of cases with ADM consistently increased nationally from 4.4% in 2005 to 22.5% in 2011. At our institution, 140 patients (53.0%) received ADM, with an increase in ADM use from 57.7% to 86.4% of cases between 2008 and 2011. In the nation, SSI occurred in 419 patients (3.4%) compared to 5 patients (1.9%) at our institution. SSI were significantly more common in ADM-ITEBR patients (4.3%) compared to non-ADM patients (3.2%) (p<0.011) nationally, while this trend was also observed at our institution (2.1% vs. 1.6%, p=0.75). Patient characteristics that were univariately significantly associated with increased rates of SSI in the entire ACS-NSQIP database included age 50 and older (p<0.001), increasing BMI (p<0.001) and greater total operative time (p<0.001). In addition, not currently smoking and absence of steroid-use trended towards lower rates of SSI but were not statistically significant. In a multivariable logistic regression model of the ACS-NSQIP database, age greater than 50 (OR 1.5, CI 1.1-1.7), BMI greater than 30 vs less than 25 (OR 3.4, CI 2.6-4.4), and operative time greater than 4.25 hours (OR 2.1, CI 1.5-2.8) were significant risk factors for SSI. Overall, our institutional rate of SSI was lower than the nation (OR 0.4, CI 0.17-1.05), although not statistically significant (p=0.06).
CONCLUSION:
The 30-day SSI rate at our institution in women undergoing mastectomy followed by ITEBR was lower than the ACS-NSQIP database. 30-day SSI was more common in the presence of ADM nationally and at our institution. Further work is ongoing to confirm if risk factors for the development of SSI at our institution are similar to those across the nation. Institutional quality improvement initiatives to reduce 1-year SSI rates in this patient population are currently ongoing.


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